Working Together: How to Build a Radiosurgical Center and Partnership

Sandra Vermeulen, M.D.

Seattle Cyberknife Center at Swedish Cancer Institute Seattle, WA

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Swedish Cancer Institute: Background

Radiation oncology providers for 7 facilities in Puget Sound area: • Swedish Hospital at First Hill • Swedish Providence Campus • Seattle Prostate Institute • Northwest Hospital • Valley Medical Center • Highline Hospital • Stevens Hospital 15 radiation oncologists treat 220 external beams patients per day, and perform 600+ brachytherapy and 300+ Gamma Knife procedures per year

Seattle Cyberknife: Driving Force

 Private Medical Investment Group: • Assessed a need in Seattle area • Approached regional hospitals and medical groups  Intent to partner with prominent neurosurgical and radiation oncology groups • Swedish Hospital logical partner choice:   Largest oncology provider in the region Large neurosurgical and radiation oncology services

Swedish Radiation Oncology Physician Group: Decision Process for Participation

   Stereotactic Radiosurgery: is there a need? • Do clinical studies support hypofractionated, stereotactic treatment?

• Are there sufficient patients to justify the device?

IGRT Platforms: is the Cyberknife the best? • How about Trilogy, Synergy, Tomotherapy?

Financial Analysis: does it make sense? • What physician resources are required, and what reimbursement will be realized?

Stereotactic Radiosurgery: Is there a need?

   GammaKnife experience proved efficacy of cranial SRS; frameless systems allow fractionation For extra-cranial SRS, literature review showed clinical efficacy in: • Spine • Head and neck • Lung • Liver & pancreas • Previously radiated sites Population of the region, and size of Swedish network sufficiently large to justify SRS unit

The World of Image-guided RT: Is the Cyberknife the best?

  Few people really understand the differences in platforms • Slow dose-rate limits throughput • Swedish Hospital had Elekta Synergy S Unit, and will be clinical/research development site Advantages of Cyberknife over other platforms: • Cyberknife only image-guided platform with real-time target correction capability • Only device with model to track respiratory motion • Greater degree of targeting freedom theoretically yields superior dose delivery

Cyberknife

Financial Analysis: Does it make sense for radiation oncology group?

  What did radiation oncologist using CK say?

• Amazing technology, excellent clinical outcomes • Enormous amount of work • Reimbursement was awful • “Just say no”, unless additional compensation given Financial per formas: hospital versus professional

Projected Hospital Revenue from CK Center

A successful CK center breaks even in year two, and can bring in 1-2 million/yr in 4 - 5 years

Professional Radiation Oncology Revenue from Cyberknife SRS

Ratio of revenue for equal work

ext beam : CK 3 : 1 (!)

Radiation Oncologists’ Reimbursement

 Why so poor?

• SRS management codes (77427, 77431) not yet reimbursed for extra-cranial treatments • Radiation oncology billing historically weighted heavily towards weekly management fees • Treatment planning codes undervalued relative to work effort required • Treatment planning effort can be shifted to surgeon (CPT code 61793), increasing patient load  Shift in mindset: must be comfortable having other disciplines participate in contouring and planning

Planning the Treatment Center

  Stand-alone center?

Association with existing radiation oncology facility allows • Efficiencies in office space • Efficiencies in staffing Physical space: hire architects experienced in medical construction • Corridors need to accommodate gurneys?

• Bathrooms, dirty & clean utilities, etc…

Assigning Staff: Cyberknife is Complex, New Technology

• Uncertainty at every step:  Indication for treatment are evolving       Treatment protocols are not well defined Every patient requires justification with insurance company Multidisciplinary treatment requires education and participation of numerous MDs and staff Numerous steps require coordination Fiducial placements – require IR – currently their work is not reimbursed Treatment planning processes (CT requirements, MR fusion) are unique, require forethought

Staffing

 Hire motivated, smart staff, preferably with experience in radiation oncology • Assign a manager to oversee the project • Physicists are expensive and hard to find • An organized, efficient RN or coordinator, is needed that can multi task well • Assign a technologically savvy, high performing therapist

Plan in Advance!

  Have manager and staff members in each domain trained through Accuray Have staff members (MD, physicist, RN, therapist) proactively plan office requirements • Office supplies • Examining room equipment and supplies • Patient charts • Treatment equipment • Physics QA requirements

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Educate Ancillary Departments

Develop written CT and MR imaging protocols: • For CT: slice thickness, pitch, # images, center, patient position, contrast agents • For MRI: location and size of matrix, scanning interval, sequence, contrast agents Interventional radiology crucial for fiducial placement • Meet with MDs, radiology office manager to explain program • Reimbursement is a problem – but other diagnostic studies can off –set their time • Explain detailed requirements of fiducial placement

Insurance

   Regional Medicare intermediary initially not paying professional fees for extra cranial SRS Will this be treatment be reimbursed? • Meet with medical director, present literature Other carriers may be reluctant to pay: • Meet with medical directors in advance • Be prepared to justify treatment with literature • Write letters of medical necessity

Educate Your Referral Base

  Market to physicians: • Relationships with referring doctors • Presentations at tumor boards, grand rounds, etc…  At local hospitals and regional facilities • Open house • Direct informational mailings Market to community: • Local media – papers, television • Website

Clinical Considerations

   Extra-cranial SRS is new and few have experiencing training Well-established treatment guidelines don’t exist Follow-up and complication data on hypofractionated body SRS is limited

To Determine Clinical Guidelines

      Attend the Cyberknife Society meetings Read the literature – CK Society has a good reference list Review radiobiology Talk with other CK Society members Amount of information is overwhelming, so assign disease sites to different doctors: • Agree on guidelines for each disease site/stage • If there is no literature on a treatment approach, submit formal protocol to your hospital IRB Consider gathering data on dosing, toxicity, and clinical outcomes to guide future treatments

Summary

      Realize enormous work effort required to start center and treat CK patients MDs should evaluate in advance the financial implications of participating Hire best available staff, preferably with radiation oncology experience Get trained and organized in advance Pro-active involvement & education of: • Insurance companies • Ancillary services (intervention radiology) Uncharted clinical waters: physicians do your homework, and cautiously write protocols/guidelines.

Conclusion

Cyberknife is a marvelous technology, that offers non-invasive treatment instead of surgery, or pain relief instead of morphine, or hope when before there was none.